A 24-year-old male underwent a laparoscopic appendectomy for a perforated appendix. Three months later he returned with sharp 5/10 pain in the right upper quadrant, a high-grade fever, and positive Murphy’s sign. An ultrasound revealed a complex perihepatic fluid collection with no internal vascularity containing a 10 mm calcification, consistent with an appendicolith, adjacent to segment V of the right hepatic lobe (Figure 1A). In addition, there were multiple high amplitude linear echoes within the fluid (figure 1B) consistent with gas bubbles. A contrast-enhanced CT scan of the abdomen and pelvis confirmed the abscess containing an appendicolith (Figure 1C) and internal gas bubbles (Figure 1D). He was started on antibiotics and a pigtail catheter was placed. A week later, the appendicolith was retrieved percutaneously under fluoroscopic guidance with a Wittich basket (Figure 1E). A few days later, a contrast-enhanced CT displayed resolution of the abscess cavity (Figure 1F).
To our knowledge, no other cases of a perihepatic abscess caused by fecalith erosion into the liver have been reported. Retained appendicoliths cause recurrent abscesses and must be removed, as they serve as a nidus for infection and are not sterilized with antibiotics.